Provider Demographics
NPI:1508257205
Name:BROEDERDORF, VERONICA ASHLEY (OTR/L)
Entity Type:Individual
Prefix:
First Name:VERONICA
Middle Name:ASHLEY
Last Name:BROEDERDORF
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:VERONICA
Other - Middle Name:ASHLEY
Other - Last Name:TOLAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3328 N SHEFFIELD AVE APT 2
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657-2281
Mailing Address - Country:US
Mailing Address - Phone:847-845-3270
Mailing Address - Fax:
Practice Address - Street 1:3328 N SHEFFIELD AVE APT 2
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-2281
Practice Address - Country:US
Practice Address - Phone:847-845-3270
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-17
Last Update Date:2024-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056010902225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist